A screening tool enhances home-based identification of adolescents (aged 10-14) living with HIV in Zambia and South Africa: HPTN 071 (PopART) Study

Introduction The HPTN071 (PopART) for Youth (P-ART-Y) study evaluated the acceptability and uptake of a community-level combination HIV prevention package including universal testing and treatment (UTT) among young people in Zambia and South Africa (SA). We determined whether a four-question primary care level screening tool, validated for use in clinical settings, could enhance community (door-to-door) identification of undiagnosed HIV-positive younger adolescents (aged 10-14) who are frequently left out of HIV interventions. Method Community HIV-care Providers (CHiPs) contacted and consented adolescents in their homes and offered them participation in the PopART intervention. CHiPs used a four question-screening tool, which included: history of hospital admission; recurring skin problems; poor health in last 3 months; and death of at least one parent. A “yes” response to one or more questions was classified as being “at risk” of being HIV-positive. The data were captured through an electronic data capturing device from August 2016 to December 2017. Proportions of adolescents who were deemed “at risk” were calculated and the association of screening “at risk” with age, sex and community was tested using a chi-squared test. The adjusted odds ratio (OR) comparing the odds of testing HIV-positive if “at risk” with the odds of testing positive if “not at risk” was estimated using logistic regression. Results In our 14 study sites, 33,283 adolescents aged 10-14 in Zambia and 8,610 in SA participated in the study. About 1.3% (427/33,710) and 1.2% (106/8,610) self-reported to be HIV positive. Excluding the self-reported HIV-positive, we classified 11.3% (3,746/33,283) of adolescents in Zambia and 17.5% (1,491/8,504) in SA as “at risk”. In Zambia and SA, the “at risk” adolescents were 4.6 and nearly 16.7 times more likely to test HIV-positive compared to the “not at risk”, respectively (both p<0.001). Using the screening tool, one-third of HIV-positive adolescents could be diagnosed using just a tenth of the number of HIV tests compared to universal testing. Conclusion The screening tool may be of some value where UTT is not possible and limited resources must be prioritised toward adolescents who are more likely to be living with HIV. Further, the tool is of greater value in settings where there are more adolescents living with HIV who are undiagnosed. However, given our goal is to identify and treat all ALHIV, as well as link all HIV uninfected young people to prevention services, this screening tool should not be a substitute for UTT in community settings. Clinical Trial Number NCT01900977 ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial Clinical Trial Number: [NCT01900977][1] ### Clinical Protocols ### Funding Statement The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIAID, NIMH, NIDA, PEPFAR, 3ie, the Bill & Melinda Gates Foundation or UK Aid. We are grateful to all members of the HPTN071 (PopART) and P-ART-Y Study Teams, and to the study adolescents and their communities, for their contributions to the research. HPTN071 was sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) under Co-operative Agreements UM1-AI068619, UM1-AI068617, and UM1-AI068613, with funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Additional funding was provided by the International Initiative for Impact Evaluation (3ie) with support from the Bill & Melinda Gates Foundation, as well as NIAID, the National Institute on Drug Abuse (NIDA) and the National Institute of Mental Health (NIMH), all part of the U.S. National Institutes of Health (NIH). RH and SFl receive funding from the UK Medical Research Council (MRC) and the UK Foreign, Commonwealth and Development Office (FCDO) under the MRC/FCDO Concordat agreement and is also part of the EDCTP2 programme supported by the European Union. Grant Ref: MR/R010161/1. The P-ART-Y study was funded by the Evidence for HIV Prevention in Southern Africa (EHPSA), a UK aid programme managed by Mott MacDonald. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics approval was obtained from the ethics committees of the University of Zambia, Stellenbosch University and the London School of Hygiene and Tropical Medicine. Permission to conduct the study was received from the Zambian Ministry of Health and the Western Cape Department of Health in South Africa. We sought informed assent and consent from adolescents and their guardians respectively I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes The data are currently held at Zambart in Lusaka Zambia and the London School of Hygiene & Tropical Medicine in the UK and can be made available on request. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01900977&atom=%2Fmedrxiv%2Fearly%2F2022%2F03%2F25%2F2022.03.24.22272873.atom